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Autonomy is a category whose attribution is associated with a number of ideas pertinent to biomedical ethics. These include ideas about the capabilities required for the exercise of informed consent, and ideas about the conditions for freedom or liberty. The individual with autonomy possesses the agency required for self-rule, and is free of any external constraints that might prevent her from exercising it. In the context of mental healthcare, issues of information privacy and confidentiality intersect with both aspects of autonomy. Agency is often compromised during episodes of severe...

Autonomy is a category whose attribution is associated with a number of ideas pertinent to biomedical ethics. These include ideas about the capabilities required for the exercise of informed consent, and ideas about the conditions for freedom or liberty. The individual with autonomy possesses the agency required for self-rule, and is free of any external constraints that might prevent her from exercising it. In the context of mental healthcare, issues of information privacy and confidentiality intersect with both aspects of autonomy. Agency is often compromised during episodes of severe disorder, and the recovered patient’s subsequent freedom to exercise autonomy is reduced when confidentiality has been breached. Because autonomy is so importantly contingent on the preservation of privacy in these settings, respecting autonomy requires unsurpassed attention to patient privacy.

The several inter-related elements here include both the patient’s own ability to ensure privacy of information (henceforth ‘privacy’), and the duties of caregivers to maintain confidentiality. The nature of mental disorder, its distinctive treatment, and the social role of caregivers all combine to leave patient privacy in considerable jeopardy. Thus, in the throes of severe disorder, patients are often unable to ensure (and indifferent about), the protection of their privacy, and the treatment they receive almost always expects heedless candour. By maintaining confidentiality, caregivers can protect patient privacy, and they have a prima facie duty to do so. Yet caregivers are required to break patient confidentiality when, because of the risk of harm to others and to the patient herself, they do so for purposes of public safety and social welfare, respectively.

What can be called the privacy stakes for the patient comprise: (1) the likelihood that confidentiality will be breached, and (2) the degree of subsequent harm resulting from that breach. And both are particularly high, I want to emphasize here. Even before the approaching digitization of medical records that will further jeopardize patient privacy, this mix of a high risk of disclosure combined with the highly negative consequences of such disclosure brings places the recipient of psychiatric care for severe disorder in a situation of extreme and continuing vulnerability.

Following the contrast between (1) and (2), the present discussion falls into two parts that correspond loosely to the two aspects of autonomy noted earlier. Laying out the ways patient privacy and confidentiality rights are in jeopardy, Section 6.2 (‘Part one’) emphasizes agency, that is, the aspect of autonomy embodied in the principle of informed consent. Section 6.3 (‘Part two’) notes how protecting patient privacy and confidentiality during episodes of severe disorder while the agency required for autonomy may be compromised, affects the subsequent freedom of the one-time patient when she has recovered.